It doesn't always go well

Death is a shadow that wonders the halls of work. He moves with unassuming quiet like some of the porters, or cleaners or security guards. He is neither grumpy nor terrifying but doesn’t really smile much either. He will pass you in a corridor or a ward and acknowledge you with a simple nod and continue around the corner - off somewhere. 

Mostly I meet him at work, but on the odd occasion I see him out and about and he mingles in my world of sometimes friends and other times family. 

It’s the familiarity that forces us to process death differently. 

We are trained to spot him coming a mile away. We are trained to deal with him when he shows up unexpectedly and escourts his patient with all the finesse of 5 burly bodyguards.

Sometimes he sits in the corner and quietly waits for days. Sometimes it seems he’s been stalking a patient for years. Sometimes it’s a little person and it seems he came too soon. 

Yet despite the frequent encounters Death is never routine. 

There is always a sinking feeling when he nods at you from across the room. 

Sometimes I am grateful that suffering comes to an end. Those are the easy certifications to do. There is relief in silent chests and fixed, dilated pupils. Those are the easy phonecalls to make and you sleep a little easier that night. 

Sometimes I am so deeply disappointed I cannot look him in the eye. Those are the lives that we fight for...the newborns who don’t breath that we do CPR on for too long. The dehydrated babies that we push needles into bones for, to get fluid into their veins. The 17 year old who had the unfortunate luck of being the unseatbelted victim of a head on collision. 

Sometimes I feel responsible, feel like Death isn’t even there; only me. 

What there isn’t usually, is time to process. There are relatives that need explanations. There are 40 other folders in the casualty box or  sick babies who need you focused. So you shelve it somewhere in your heart...and like that journal article that someone gives you to read, you never actually come back to it. And one day you notice you are quite good at switching off emotion when Death walks into a room. And you accept that like taxes it is inevitable, and you remind yourself that God and not your capability or inability decides who lives and who dies. 

And you focus on the ones who live. 

On the Tweety’s who nearly died of TB and malnutrition but then who came back to visit us  3 months later flourishing and healthy. 

Or the Thato’s, who’s mom we counselled thinking her 8 year old at worst would die  of TB Meningitis and at best would be severly brain damaged, yet went back-to-his-old-self-Thato and came back a few months later bragging about how well he’d done in his school athletics.

Or the Owami’s who we thought would never come off CPAP. 

OrThe 700grammie who now weighs double and has proved me wrong! 

I suppose you appreciate life more when you become familiar with Death.

My little superheroes

It’s easy to forget that this is actually a hospital up on the E-floor. 

These super specialist paediatric wards become second homes for so many of these kids. They come with their broken livers and kidneys and carve out a place for themselves in this little family. 

In this ward there is no such thing as a short stay - an admission here is typically never less than a week, and sometimes stretches out for four or five months. 

It is well described that kids eventually adapt to any environment - although it may trigger a few abnormal and sometimes worrying coping mechanisms. 

It doesn’t happen overnight, as is certainly evident in the more general wards where the kids are being exposed to the hospital environment for the first time. There they regard every approach with cautious apprehension - never sure if something unpleasant and painful is about to happen.

But upstairs they slip into the routine of the ward. They call the nurses by their first names. They know the names of all their medications and when they have to take it.

If you spend more than 2 days in the ward with them they greet you with running hugs in the morning and blow you kisses from their beds on ward rounds. 

They get beyond excited when they are well enough to join the other kids at the hospital school. They all know Bubbles the clown comes on Thursday morning. 

Downstairs in the B-wards it’s easy to remember you’re in a hospital for sick kids. 

Up here I have to actually remind myself that these kids are sicker. These are the babies who have had more general anaesthesia than I will probably ever have in my life. These are the kids who have survived transplants, life threatening infections and cancer after the immunosuppresants we gave them stopped them from keeping the abnormal cells in their body in check. This is where most of the blood that you donate lands up - not in a trauma ward, but in a ward with chronically ill patients. 

Yet they have so much life in them I struggle to imagine them not living a full one.

I forget when in the afternoons after the dialysis machines and gancyclovir infusions have been disconnected, and the kids are racing around in the corridor wearing their ‘duck-bill’ masks, that this is not a playground.

I forget when Tracy comes around with her arts and crafts that this is not a classroom.

I forget that they have chubby cheeks not because they are fat and flourishing, but because of the steroids that keep them from rejecting their organs. 

I forget when it’s time to drip one of them and she points out which veins are better - that kids are supposed to be afraid of needles. 

I forget that these  kids  are living on borrowed time and that big school and dreams of being ballerinas or pirates may never come true. 

Working with them has been an eye-opening and humbling experience. 

My little superheroes. 

The Universal Pen Theory

Some people may think that the essential tool of any doctor is maybe their stethoscope? Maybe needles and syringes? Perhaps a defibrillator (picture a flatline on a monitor, someone shouts Vfib and then they pull out these paddles and call "Charge to 300")? Perhaps an ENT set or those nasty ice-cream sticks that no one loves?
No not true.
You see surgeons' stethoscopes gather dust and I don't think a radiologist would know what a defibrillator was if you showed it to him and said the word r-ea-l-ly sl-oooooow-l-y.

No. The essential tool of any doctor, the one thing that unites us all and leaves us lost and useless at work in its absence is a pen. Specifically, a black pen.
Blue is apparently tantamount to giving an A+ patient, B+ blood, it would seem. I once dared to use a blue pen because I could find no other pen to make notes with, and the sister in charge of the clinic sent the whole folder back and informed me with a very straight face, that I had to rewrite everything from the consultation; notes, prescription, admission forms and consent documents, because no where in the hospital would they accept blue pen notes!
Allegedly, blue does not photocopy well - and makes keeping records of the records problematic, which becomes problematic when you need your notes to defend you in a lawsuit somewhere down the line. Hey - you hear the word lawsuit you do what people say...but I think the bureaucrat that came up with that fallacy had a standard issue government photocopier that probably hadn't been serviced since the stone age.

I digress...the point I actually wanted to make is a secret of the universe that I have discovered which is guaranteed to cut down on pen frustration everywhere.
You see, pens - like socks and teaspoons, have this annoying tendency to disapparate. One minute they're in your pocket and the next minute they're gone.
Any doctor worth his MBChB salt avoids pen frustration by firstly never buying anything more expensive than a standard Bic Click pen, and never having less than at least 2 in your bag. Drug reps also usually provide handy emergency stashes, but emergency is all that they qualify for. They are designed to get you to the end of the day only - their life force is simply not strong enough to survive more than a few hours of government doctor writing.
The loss of a trusty Bic Pen produces profound pen anxiety. There simply is very little you can do in your day without one. It is somewhat alleviated by borrowing a pen from a colleagues emergency stash.  Some anxiety still remains however, as the possibility of returning the pen is slim to none. No one intentionally steals a pen. Everyone does it purely by accident...but the stigma remains in our minds none the less.
Failure to locate a good samaritan results in you taking on a desperate search of the local environment looking for a lonely pen that has been neglected by it's owner. The charge on your head is so much greater for the day though...kidnapper!

It's all been for no good reason.
You see, pens are not property of individuals (the one exception being fancy Parker pen sets with names engraved on them).
Pens are property of the universe.
Bic pens especially are so standardised they gave themselves away immediately. I myself on many occasions have unintentionally neglected to return a pen to it's rightful owner and on one occasion I can remember being desperate enough to kidnap one. At the same time, I lose a pen a week, at least, and as such I am constantly adding to the universal pen fund. If I manage to get a Bic pen to the point where its ink runs out before I lose it, I basically throw it a funeral. I also keep more than 2 in my bag so that I can give them out freely to the universe without needing them to return.
I haven't had pen anxiety for ages...and neither should you!

R.I.P.

(This is not a post for sensitive readers. )


We had a lovely Pup that lived with us once. She was a real ‘pavement special’ - the markings (and the mind) of a Jack Russel but with the coat of a maltese mongrel. I have loved all my dogs equally, but Pixie lives in a special memory box.

She could beg before she was house trained. If she didn’t want to sleep outside she would jump up and down outside the bedroom window until you let her in. She followed you around all day if you were at home...from room to room just keeping you company while you got on with your day. 

She loved cheese. Loved it. 

But Pixie developed a heart condition, which presented with the most awful epileptic-type seizures. She had a dilated cardiomyopathy and spent her last 2 years on blood pressure medication and a diuretic. She aged but never lost her character. And when her heart failure got so bad that she swelled up like a balloon and was struggling to breathe we asked the Vet to put her down and he obliged.

In my year of being a medical officer in Potch a baby was delivered in labour ward who had the misfortune of being knitted together wrong.

He was born with an oesophageal atresia and so basically his oesophagus dead-ends before it gets to his stomach. While it is surgically correctable, in the interim feeding such a tiny poppet is tricky. 

It took about 3 days to get him transferred across to Baragwanath, the only paediatric surgery unit for about 3 provinces, by which time he had developed a bit of a cardiac murmer suggesting that more than one system had developed abnormally.

I can’t be sure, but I vaguely remember that the Baragwanath doctors confirmed him to have a Trisomy 18 - and largely because of this and his cardiac issues he was denied any surgical intervention - based on the fact that we are in a resource stressed environment, are dealing with a child who is unlikely to survive anaesthesia or post-operative care based on his abnormal heart and has a lethal genetic condition. Even if they could put him vaguely together again - he probably wouldn’t see his first birthday.

So Bara sent him back...

And here we sat with a not-even-2kg-baby and no way to feed him. Sent back to die...slowly. 

We had a drip up because it just seemed cruel to let the kid die of dehydration. Instead we waited for him to die of starvation instead. Waited for 3 weeks.

He lived in a little incubator in room 4. He spent most of his days alone because I literally saw the mom once about 2 days before he passed away. The only time he was touched was when his nappy was changed or when he was examined or when he was dripped. 

After 3 weeks he became undripable...the few veins left hidden under swollen soft tissues because he must have had no albumin left to keep the fluid in his veins. 

I probably spent 6 hours of that day trying to get a drip up on him because I couldn’t bear the thought of him lying there and getting thirstier and thirstier and unable to drink anything. And I left completely defeated and prayed all night that God would take him before morning.

He didn’t. 

He was still there. 

And the next morning too....

We seriously considered euthanasia - despite the fact that it’s illegal we put it on the table. None of us could bear to watch this baby suffer any longer. We picked a drug and called the parents in to explain what our intentions were. 

As if all he had been holding on for was a chance to say goodbye, when his mom arrived and cradled him in her arms he finally breathed his last. 

So in the end we never needed to, but it’s always going to bug me...

We treat our animals better than our people.

Debrief

You be my psychologist, because I basically work in a war zone 60 hours a week and I don't sound these things out enough. Some things have hung around in my head for the last little while.





I saw a 7 week baby on Friday morning, who was referred in because of respiratory distress. According to the mom she started breathing fast the previous afternoon... no coughing, no fevers, no issues feeding. The baby was beautiful... and blue. Her oxygen saturation in room air was low 70%...(this is baaaaaad.) A bronchodilator didn't do much, a 100% oxygen got her sats into the high 80's. An x-ray a big fat heart! Blood gas shows a pC02 of 7.3 and a lactate of 10! Prognosis is worsening.
Within 3 hours she was reviewed by an ICU doctor and a cardiologist who with a 10 minute echocardiogram diagnosed this little nunu with TAPVD - total anomalous pulmonary venous drainage...basically, the pulmonary veins don't connect with the heart, so the heart pumps blood to her lungs but then it dead ends...the only thing that's kept her alive for 7 weeks is an ASD (atrial septal defect) which allows some mixing of the pulmonary and systemic circulation.
And I watched a mom watch us make a diagnosis on her child. And I watched her get told that her 7 week old baby girl, who seemed perfectly well on Wednesday, needs emergency open heart surgery if she wants a shot at life.

On my rounds this morning I had to see a 3 year old little boy who weighs 8kg. He managed to escape getting his mom's HIV but unfortunately not her TB last year or her poverty. He's had an admission for severe malnutrition once before in his 3 short years. Now he's back...with a round puffy kwashi face and a stick thin marasmic body, the skin on his tummy is loose like and old man's. His electrolytes are in the floor, he's temperature is through the roof, his chest X-ray is a disaster and he won't eat - dying of starvation in the shadow of Table Mountain.
His mother sits next to him with a sad, bewildered look on her face. She doesn't speak a word of english. She doesn't look super healthy herself. I know she doesn't realise that he's so sick he probably won't pull through and I wonder how did they get to this point - twice. It's easy to blame.
But when I take him through to the procedure room to do more bloods I watch her put her face close up to his and comfort him with words I don't understand and soothing smiles... and a little voice whispers in me..."she's doing the best she can."

Upstairs in B1 high care is the loveliest little kid. Mich lived in B1 from February to May getting TPN (total parenteral nutrition) - which is food in a drip - but hectic R1000 a bag, too corrosive for small little arm veins, has to be run through a central line (sited directly into one of the big vessels in your chest or abdomen) stuff.
It also meant she could have absolutely zero food orally because a combination of her HIV and a couple of nasty stomach bugs have wrecked her intestines so badly that not only does she absorb nothing but eating something actually just damages her gut even more. Imagine being 5 years old and not being allowed to eat a thing!

She made it home for a few weeks, getting by with a lactose free diet...picked up a stomach bug and is back at square 1. Weighing in at 12kg's she is a scrap of the little sunshine kid she really is. She is lying propped up by a few pillows, shuffling through songs on one of the nurses cell phones. Realistically I'm not sure she's got more than a year of life in her body, though her little soul has fight for a few more. She starts listening to a Celine Dion song "Goodbye's the Saddest word"... and that was the end of me. I had to leave.

Christmas cracker instructions

From the Comserv Files

So there we were... trapped somewhere between Saturday and Sunday.
I imagine because it was about 2-o-clock in the morning and because both of us were still in casualty, it means that it was a standard Saturday night comserv call - attempted murder and mayhem, unidentified drunken injuries and the old faithful GBP's (generalised body pains which is code for end stage HIV and MDR TB because I stopped taking my ARV's again, 7 months ago).
If things had been semi manageable we would have split up for a bit of rest or supper.
But no - we were both there.

So this guy comes in with acute urinary retention and by the scar just above his pubic bone - this is not the first time his pipes have gotten blocked. I reckon after having a baby and allegedly a kidney stone - this has got to be the 3rd most unpleasantly painful condition - to have a litre of urine in your bladder and not be able to get rid of it.
He was not happy.
So we tried the conventional catheters - we tried the small ones, and the big ones, I tried and Dr S tried. No luck.
It was very obvious that the only way to get this beer byproduct out was to access it from the slightly less conventional route - trans abdominally.
Basically this involves shoving a trochar (medical jargon for a needle the size of a thin pinky finger) through your abdomen in the vicinity of your bladder to create a hole big enough to feed a catheter in.
We use a bit of local anesthetic - emphasis on 'a bit'.
Having done a few subsequent to this story I can now say that putting one in is a lot more benign than it sounds, but when you haven't been exposed to the machinery before, you are terrified. You see - abdomens do not only house bladders - they house a few other organs which do not take kindly to being pierced with big ass needles.
(In reality - if you're at the point of putting in a suprapubic the bladder should be the size of a small baby and in the way of most of these organs - but you never consider that when you're confronted with your first few.)

"Have you ever done a suprapubic?" I ask Dr S - confident that at some point in her 2 years of Baragwanath internship she must have done at least 1.
"No." was her slightly less confident answer.
Nervous laughter.
"Me either!"
So I'm thinking - 'Don't panic! I'm sure these suprapubic packs always come with instructions so...'

Dr S and I get our little trolley together - trying to think of pretty much everything we could need bearing in mind our poor patient is rocking and rolling on the bed in the casualty cubicle.
What was slightly disconcerting was that our instruction manual looked like it came out of a Christmas cracker...seriously it was about 3 x 5cm piece of paper with font 6 writing and no punctuation

"Ok, one of us must instruct and one of us must do...what do you want to do" I asked Dr S
She looked at me like I was asking the stupidest question in the world...
"Instruct."
Sometimes my calmness surprises me, and maybe at this stage of the year I had enough confidence to not care or my adrenal glands had burnt out. There may have been just a teeny tiny shadow freaking out inside of me though.
"Ok." Here goes nothing I think.
"Step 1: Clean the area..." fairly straightforward.
"Step 2: Inject local anesthetic over the area..." again - fairly straightforward. Patient not to happy about the 10mls of lignocaine that gets distributed between bladder and skin - but it's a lose lose situation for him.
"Step 3: With the scalpel make a 1cm incision approximately 1cm above pubic symphysis." Straight forward again.
"Step 4: Insert trochar..." Ok so this is where it stops being straightforward. There's this plastic sheath around the trochar that stays behind when you pull the trochar out to leave the hole that you just created open. Problem is, as you push the trochar deeper into the abdomen the plastic sheath slips down over the front of the trochar and well - it becomes a case of cutting flesh with plastic - in a word; ineffective.
Also - what you don't realize when you put a suprapubic catheter in for the first time is that there is actually quite a bit of tissue to get through before you hit a bladder. Of course you start freaking out half way thinking how can I not be in the bladder yet...surely I've missed it and I'm about to hit the aorta!
"Are you sure that's what it says Dr S?" I ask, seemingly making no headway while the patient writhes in agony - a combination of a full bladder and having minor awake surgery performed by 2 would be pediatricians. "Are you sure we didn't miss a step?" and that little freak-out voice is getting louder.
I take the trochar out, I make the incision deeper with the scalpel, I try again...not quite working...
"No I don't  think we're doing anything wrong" Dr S encourages me meekly from the side..."Just keep going..."
So we continue to slowly push through the tissues - sometimes smoothly with sharp trochar, sometimes less smoothly with blunt plastic. Eventually there's a give and a veritable fountain of urine. Patient and Doctors are both covered in urine but very much relieved (no pun intended).

There's something awesome about getting these things right on your own... a little bit of a confidence boost for the next time you find an imminent breech delivery or a patient's heart stops beating in front of you.
Then there's the post-panic laughter that descends after the catheter's in and secured with a stitch, and the realization that this is not Greys Anatomy medicine which is supervised and sterile. This is South African medicine which is powered by camaraderie and Christmas cracker instruction leaflets.

Worth his weight in Gold

He's a big little boy. Bright eyed, well spoken, full of smiles.
"How are you today?" I asked.
"I'm fine thank-you" (Can I just this point out that very seldom does a child respond to any kind of questioning - let alone with such beautiful english and manners. They usually bury their faces in their parents arms or take one look at the stethoscope and identify you as an enemy.)
"You can't be that fine if you're here" - referring to the short stay ward where I'm working this weekend.
And there it is - a big goofy smile.
"So what's the matter?" I ask.
"I've been struggling to breath and my chest hurts"
"Since when?"
"Since about Thursday."
"And have you been coughing?"
"Yes - yellow phlegms"
"And fever?"
"I think so."
"How old are you now?"
"I'm 15" - goofy smile.
"And are you in school?"
"Yes."
"What grade?"
"Grade 8."
"And what's your favourite subject?"
"Maths"
"Oh - you're one of the clever boys!"
A bashful version of the goofy smile appears.
"Ok lets have a look."

He doesn't look 15... maybe 10. And at first glances in the ward you might mistake his crumpled frame for a CP child. There's absolutely nothing wrong with his brain though.
He's got SMA (spinal muscular atrophy) type 2 - a slightly less lethal type than type 1 which is fatal before 2 years of life in the best settings. Type 2 causes progressive muscle weakness and paralysis of the body due to a defect in anterior horn motor neuron cells of the spinal cord. (Basically the cells that control the nerves that control your muscles.) It's a genetic condition for which there is no cure. Most of these kids live not much further than their teens - mostly battling pneumonias there whole life long until eventually one cannot be beaten.

This little guy can no longer sit unsupported and he has very little use of his arms. He has a scoliosis which is compromising his already diminished lung function even more. His chest is badly deformed - I can hardly think there is much lung tissue on the right hand side.
He's got a raging pneumonia - but he's perky and chatty and polite.

While I draw blood and put up a drip he asks "please don't put it in my right arm because I can't write with it then." He moans that I'm not using the smallest needle and when I don't hit blood the first time he calmly suggests "maybe you should take it out and try again."

He is an absolute treasure. Worth his weight in gold and equally resilient in the face of the heavy hand that life has dealt him.  It breaks my heart and warms it all in one beat.
These are my favourite kind of patients.

On call phenomena

No call is the same. Sometimes they're crazy crazy busy. Sometimes they are unexplainably quiet. 

Certain things about calls are universal though...

Here follows a brief guide.

Pre-call blues.

Calls always start about 24 hours before the actual call - you have to go through the mental paces of preparing yourself for 24 hours (plus) of work. Naturally, a certain amount of depression accompanies the mental anguish of the task. The necessity of mental prep is most obvious when a call is sprung on you (i.e finding out on the day that you're on call that you're on call) when it suddenly your day goes from being an ordinary work day with the usual 'me time' at the end to suddenly being the day that never ends, with very little 'me time' at all. 

On call food bags

Food bags are always excessively full when you come on call. This is simple - if you're gonna be miserable at work, no reason why you should be hungry miserable too.

On call karma

There are some people who, whether by stupidity (people who look for work) or dumb unluck, have horrendously terrible calls. Their penchant for attracting nearly dead P1 patients is freaky. They're usually amazing doctors, and if the proverbial pawpaw is going to hit the fan you'd want them nearby - but still. If you're on call with them your pre-call blues are always a little more intense because there is always hope at the start of a call that it won't be too bad...sometimes though, you just know - unlikely!

The Q-word

Much like saying 'Macbeth' in a theatre, no one refers to a call being 'Quiet' until the call is over. Legend dictates that invoking the Q-word calls down the mischief of Murphy and somewhere nearby a passenger train derails, 30 cars pile on top of each other at high speed, labour ward fills up with twin pregnancies and breeches and someone starts bleeding - a lot. My rule is if you say the Q-word, you do the work that follows.

Post call EUPHORIA

The unexplainably, yet very real endorphin rush, when you walk out of the hospital post call. No matter how little you slept, how hard you worked, how dirty or smelly you are, whether people lived or died, whether you pulled any rockstar moves or not - you always leave with the same elation.

Post-post call

This is probably the most famous phenomenon. It is widely described by medics of all ages, disciplines and universities. 

Mostly, post call days are spent supine...on a bed or a couch of death...with junk food...watching mindless TV (E entertainment never fails). But these are great days actually. It's the next day - the one when you have to go back to work that you feel the weight of too much work.

It's a mystery. You would think 18 hours of sleeping would leave you refreshed. 

Best explanation I've had to explain it is "you're still actually tired from the call. Problem is you now lack the post call euphoria." 

Haven't found an explanation that comes closer.